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Health economics of statin

 

Clinical bottom line

The cost-effectiveness of statins is dependent on the baseline level of risk at which treatment starts. At a 10-year risk of 30% the overall costs are bearable, but by 15% 10-year risk the costs are huge. Until we know the aquisition costs of newer statins, simvastatin and atorvastatin seem the best buys.



The health economics of statins are usually addressed in two ways, the absolute cost in terms of life saved, and comparative costs for different statins.

Establishing the cost of statins for a quality-adjusted life year (QALY) or year of life saved (YLS).

Here the issues are the cost of drug acquisition (essentially the price of the drug), and the level of risk in the target population. Results of some studies in this area are shown in Table 1.

Table 1: Health economic studies of statins

Reference

Type of study

Main findings

Sponsorship

Cost effectiveness of statins
Jacobson et al, 1998 Literature review examining effectiveness and costs of statins, with estimate of cost per year of life saved Concluded that, compared with other interventions, statin use in secondary prevention is cost effective, and in some groups in primary prevention. Sponsored by manufacturer of a statin
Ebrahim et al, 1999 Literature review examining cholesterol lowering, including statins, with cost analysis Cost of life-year gained at different levels of risk, and of different statins. At 10-year risk of 30%, range of costs was £3,100 to £6,200, depening on whether discounter or not, or gross or net costs. No sponsorship
Yeo & Yeo 2000 Estimate of costs associated with implementation of National Service Framework in UK Using a GP list of 2,000 patients, with 1,000 aged 35-64 years, cost of statins drugs would be up to £37,000 a year to implement a policy of treating all with 10-year risk of 30% or more No sponsorship
van Hout & Simoons, 2001 Modelling exercise for Holland, based on literature review and initial risk of new coronary heart disease events Based on an arbitrary threshold of a cost effectiveness of Euro 18,000 per year of life saved, treatment should be targeted to those with a 19-26% 10-year CHD risk. This is affected by age, varying from 11% under age 30 to 41% over age 80 years. No sponsorship
Comparison of costs of different statins
Koren et al, 1998 Cost of achieving LDL-cholesterol target based on RCT of four statins in USA over one year Atorvastatin and simvastatin had lowest cost, and lower than fluvastatin and pravastatin over one year, and more patients (90%) achieved target LDL-C. Based on cost of drugs and doctors office visits. Sponsored by manufacturers of atorvastatin
Smith et al, 1998 Cost of achieving LDL-cholesterol target based on RCT of four statins in Europe, over one year Atorvastatin and simvastatin had lowest cost, and lower than fluvastatin and pravastatin over one year, and more patients (90%) achieved target LDL-C. Based on cost of drugs and doctors office visits. Sponsored by manufacturers of atorvastatin
Attanasio et al, 2000 Cost of maintenance on statin therapy after target LDL-C reached Cost minimisation analysis of simvastatin versus atorvastatin based on results of final statin doses in Smith et al, 1998. Concluded simvastatin cheaper by 7-40%, depending on prices in different countries. Sponsored by manufacturer of simvastatin
Huse et al, 1998 Cost effectiveness of different statins and doses based on cholesterol reduction in a US setting Concluded atorvastatin cheaper than simvastatin cheaper than other statins. Sponsored by manufacturers of atorvastatin
Russell et al, 2001 Cost effectiveness of different statins and doses based on cholesterol reduction in a Canadian setting. Virtual duplicate of Huse et al. Concluded atorvastatin cheaper than simvastatin cheaper than other statins. Sponsored by manufacturers of atorvastatin
Maclaine & Patel, 2001 Dose escalation comparison of statins to achieve a target LDL-C based on cholesterol reduction Concluded atorvastatin cheaper than simvastatin cheaper than other statins. Sponsored by manufacturers of atorvastatin
Sponsored in this table is taken to mean an explicit acknowledgement of sponsorship, or an author from a pharmaceutical company, or both

We know that the higher the level of risk, the more effective the statin will be, for instance in terms of the NNT for preventing a bad outcome like fatal or non-fatal heart attack or stroke. With five years of statin treatment NNTs fall from 91 at a 10-year risk of 5% to 9 with a 10-year risk of 50%. And clearly a statin that cost £100 a day would be less cost-effective than one that cost £0.01 per day.

Many of these analyses are based on the results of the large outcomes studies with statins, often with evidence brought in from other areas to bolster arguments. A typical review [1] concluded that the cost of statin treatment for secondary prevention and primary prevention for people with higher risk, was about $45,000 per life saved, in the same range as other typical healthcare interventions. A good Dutch study [2] took a slightly different view, putting a ceiling of Euro 18,000 as an acceptable cost-effectiveness figure for year of life saved, and concluded that people with a 10-year risk of about 20% or more should be targeted. There were interesting age-related differences, with lower risk perhaps being treated in younger people, and higher risk in older people.

The most useful economic analysis from a UK perspective was an HTA review [3]. This extensive systematic review and economic model confirmed that the two major effects on cost were the initial risk, and the cost of the statin. It gives estimates of cost per life year gained as gross, or net of other interventions prevented, and discounted or undiscounted. The net discounted costs of statin treatment at different levels of risk are shown in Figure 1. At a 30% 10-year risk of mortality it was £4,727.

Figure 1: Net discounted costs of statin treatment at different levels of risk


Yeo & Yeo [4] actually worked out the costs of implementing the National Service Framework (NSF) for coronary heart disease (CHD) in general practice in the UK. This was based on a survey of risk in 8,000 Scottish adults, of whom 3,251 were aged 35 to 64 years and were not taking lipid lowering therapy. Of these:

Figure 2: 30% 10-year risk or more


Figure 1: 15% 10-year risk or more


Thus about 8% of the adult population between 35 and 65 years would need statin treatment to implement the NSF. The approximate costs for a typical GP practice with about 1,000 people aged between 35 and 64 years would be about £35,000 to treat those at 30% risk or more, £70,000 for those whose risk was 15% or more over 10 years, and about £170,000 for those at a 10-year risk of 6% or more.

Comparative costs of statins

Here the issues are more simple, because in the end it all comes down to the cost of effective statin doses. The arguments used here include percentage reduction in LDL cholesterol, though a major problem is the paucity of quality data from large numbers of randomised patients, and information is often quoted selectively. Two studies [5,6], used randomised trials of statins with dose escalation built in to reach target LDL cholesterol levels, and then calculated the one-year cost of reaching the target based on drug costs and doctors office visits. Another [7] examined the maintenance costs after targets had been reached.

All of these studies [5-10] concluded that the cheapest option was the statin from the sponsoring company. Where several statins were studied, two, simvastatin and atorvastatin, generally were more cost-effective, with usually more patients hitting LDL cholesterol targets, and fewer dropping out.

Comment

None of these studies is perfect. Practical issues are often overlooked, particularly withdrawal from treatment that could limit any possible success on a population if not an individual basis. There has been at least one attempt to examine models used in predicting future events in cost-effectiveness work [11]. It concluded that in the UK situation more attention should be placed on achieving the goal of the ratio of total to HDL cholesterol, since that was what targets were based upon.

The bottom line is that statins are certainly cost-effective for those with a 10-year CHD risk of 30% or more, but that costs would limit a lower treatment threshold. Many individuals with a 10-year risk of lower than 15% and with a total cholesterol above 5 mmol/L or a total to HDL cholesterol above 5 might also judge that buying their own statin would be a personally sensible cost-effective purchase. As the public become more educated about risk, the level at which the state pays and at which the individual pays will become a hot potato.

Reference

  1. TA Jacobson et al. Maximizing the cost-effectiveness of lipid-lowering therapies. Archives of Internal Medicine 1998 158: 1977-1989.
  2. BA van Hout, ML Simoons. Cost-effectiveness of HMG coenzyme reductase inhibitors. Whom to treat? European Heart Journal 2001 22: 751-761.
  3. S Ebrahim et al. What role for statins? A review and economic model. Health Technology Assessment 1999 3: 19.
  4. WW Yeo, KR Yeo. Workload implications and cost of statin treatment in the National Service Framework for coronary heart disease. British Journal of Cardiology 2000 Suppl4: S11-S18.
  5. MJ Koren et al. The cost of reaching National Cholesterol Education Program (NCEP) goals in hypercholesterolaemic patients. Pharmacoeconomics 1998 14: 59-70.
  6. DG Smith et al. Cost of treating to a modified European Atherosclerosis Society LDL-C target. Clinical Drug Investigations 1999 17: 185-193.
  7. E Attanasio et al. Cost-minimization analysis of simvastatin versus atorvastatin for maintenance therapy in patients with coronary or peripheral vascular disease. Clinical Therapeutics 2001 23: 276-283.
  8. DM Huse et al. Cost-effectiveness of statins. American Journal of Cardiology 1998 82: 1357-1363.
  9. MW Russell et al. Cost-effectiveness of HMG-CoA reductase inhibition in Canada. Canadian Journal of Clinical Pharmacology 2001 8: 9-16.
  10. GD Maclaine, H Patel. A cost-effectiveness model of alternative statins to achieve target LDL-cholesterol levels. International Journal of Clinical Practice 2001 55: 243-249.
  11. R Grieve et al. Selecting methods for the prediction of future events in cost-effectiveness models: a decision-framework and example from the cardiovascular field. Health Policy 2003 64: 311-324.